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The greatest public health crisis in Kenyan history was the advent of HIV/AIDS, particularly the initial stigma, ignorance and extremely high cost of would-be treatment. Dr Craig Cohen has been here right from the start and explains to Wycliff Muga what is was like to be a pioneer in the war on AIDS

WYCLIFFE MUGA:  I will start by asking how you first got involved in HIV research. I’m taking the point of view of you as a researcher, primarily. I know you also have administrative duties.

 

DR. CRAIG COHEN:  So, I’m an obstetrician-gynecologist. And while I was in residency at Northwestern, actually I was exposed to what I call reproductive infectious diseases, which includes HIV, from a woman’s perspective at least. And, then when I was in Northwestern, I set up an…

A: That was in 1990.

 

Q: Over twenty years ago.

A: Yeah, exactly. So, when I started residency (it’s four years in the US) and I got exposed not to HIV so much, but at least to the concepts of what I call reproductive infectious diseases.  I then went off to Northwestern and at that time I decided, well, I either wanted to do academic medicine and potentially with some international focus but I was uncertain at that time ‘cause I didn’t really have role models in Ob/Gyn..  Or there’s something else I wanted to do.

So I set up an opportunity for myself. This was the early days of e-mail.  Early nineties. Now it’s so easy to send people messages but back then it was very difficult. But I sent messages out to people – that I looked at the literature around HIV and women. So I sent it out to maybe, maybe 15, 20 people.

And either people didn’t respond – maybe their e-mail wasn’t working or they just didn’t respond. Even the person who became my first main mentor at the University of Washington where I did my fellowship, said there’s no there’s no way   I only had a six week-elective in my residency – there’s no way you can get anything done.

But then Anne Duerr, at CDC said, “We’re starting a new project in Chiang Mai, Northern Thailand, with some researchers from Thailand, the Ministry of Health and with Kenrad Nelson who is now Professor Emeritus at Johns Hopkins University.  “Might you want to come with us, and we’ll set something up?”  I said, “Sure.” So, I then took some time, I went to Atlanta,  met with her, we talked about some ideas. I went to Baltimore, I met with Kenrad Nelson, we talked about other ideas.

And then, lo and behold, I found myself in Chiang Mai for six weeks. We designed the protocol. This was a different regulatory time. We designed the protocol then we got IRB approval within like a week. Obviously nowadays it doesn’t work that way.

 

Q: IRB is?

A: Institutional Review Board or Ethical Review Committee. We got it within a week, but nowadays it obviously takes months and months. But, the hunch that I was working on was that women who, are, I thought…there is a condition called bacterial vaginosis (BV) which is, simply… so the normal vaginal flora is predominantly lactobacillus, acertain species of lactobacillus.  Some women though have abnormal vaginal flora predominantly anaerobic bacteria, bacteria that don’t need oxygen. Causes discharge.

And I had this hunch that maybe either BV would be more common in women living with HIV or BV because it could affect the female genital tract, could make one more susceptible to HIV.

So we ended up doing the first cross-sectional study so we looked at…we worked with young sex workers in Chiang Mai and just essentially correlated back to vaginosis with HIV among 144 young sex workers in Thailand. And, lo and behold, I was right.

The hunch was right. There was an association. We couldn’t prove cause and effect. We didn’t know if BV was more common because the women were HIV positive or BV was present and the women that were more likely to get HIV positive. We didn’t know.

But at least it was the first paper that came out, the first study completed that demonstrated this association. I should say also when I was in Chiang Mai, I mean these, as you can imagine what sex work at least at that time in 1993…

 

Q: Thailand is notorious.

A: …what sex work was like in that period of time. That these were girls. I mean, they had to be 18 to be in the study, but I actually went with a public health officer to visit some of the brothels.  It’s mainly brothel-based. Or at least most of the sex workers that we studied were in brothels. Some were indentured servants literally…So we visited them and there’s this plate…and you’ve probably read or seen… The plate-glass windows.  There are these little numbers, you know, you pick numbers, if you’re the man and you pick number 121…. And I was just, I was really just so sad, I was just like, something has to be done. And this was a time, this was the peak of the HIV infection time. Since that time, the infection rates have gone way, have just plummeted. It’s really fantastic what the country has been able to do. But I would come back from work and I would just lay on my bed every evening for like an hour. You were mentioning Bach being very emotive. I mean, for me I don’t cry like that per se, but I just was like, just in shock.

 

Q: At what you had seen the whole day?

A: At what I had seen. And just that 40 per cent  of these young women were HIV positive. Were living with HIV.

 

Q: 40 per cent?

A: 40per cent. These were sex workers. I mean, there’s been a high per cent… they, you know, sex workers, young girls that are mostly… 40 per cent were positive. So I, I came back from Thailand and I said, “This is what I want to do.”  I mean, that’s the way I’ve made decisions in my life usually. My big decisions. Is I don’t just read a book or think or talk to people. I mean, that’s all part of it as well, but I really want to experience it. See what, see something that grabs me that I feel like I’m good at.

And I decided then when I was in Thailand that I wanted to do what at the time was called infectious disease, but now I call reproductive infectious diseases. I applied to the only fellowship programme I knew which was back at the University of Washington. I had made good contacts there with people because I had spent one year there and I knew some of the researchers there. Anne Duerr helped as well. And, I told them about my experiences, applied, and, lo and behold, they accepted me into the programme and Joan Kreiss, who was my first mentor, was also the person who I think is credited with identifying that HIV was a problem in Kenya. Was that in 1993 or 4?I think it was about 1993 that she did her sero-prevalence study at Buffalo Bill’s in Nairobi.

 

Q: Oh, I’ve heard of that . . .

A: Yes. So she did the first study. Also on a hunch that there was HIV in Kenya. Most people were saying that there’s no HIV…

Q: But there was already HIV in Uganda by that time?

A: There was a lot of denial and nobody looked. And the research community was focused on STIs. Mainly those that cause ulcers like chancroid and syphilis and so forth. People were not looking at HIV. But, lo and behold, she found maybe it was earlier than that, actually, maybe 1991…but she found, in her study, that she just, she rented a hotel room at the hotel there…she found HIV. So she became my first mentor and she had a study that was already funded to look at the effects of HIV infection on women who suffer from something called pelvic inflammatory disease, also known as PID, which essentially is an infection, mostly a sexually transmitted infection, that infects a woman’s uterus, her tubes, fallopian tubes and her ovaries and also can cause something called peritonitis. They can get quite ugly, abscesses and so forth.

So that, so she said, “We have a study in Kenya, would you want to do this?” And I said, “Sure.” So, when she accepted me, it was under the pretext that I would be coming to Kenya, originally for fifteen months. One study I started was at Kenyatta… actually, when I moved here in 1994 July, the doctors, you might remember this, the doctors at Kenyatta National Hospital were on strike.

 

Q: Oh!

A: So the hospital was essentially…

 

Q: Closed?

A: Closed. So I started the study at Kikuyu Missionary Hospital because I thought maybe I could recruit patients there. But it ended up, I mean, I ended up doing some good work there, getting started but there weren’t, they didn’t have the patient volume that KNH hadso I moved to Kenyatta once they re-opened in about October, soI got a little slow start. But, umm, the work was…we had a small team, me, a nurse, a clinic assistant who still works for us, and a driver, who does not work for us …And, I guess that’s it. And I did everything. I was the doctor, I was the researcher, I was, we did – it was an inpatient study – so, I was the obstetrician and gynecologist, we did something called laparoscopy, a minimally invasive surgery to actually confirm the diagnosis and then to drain the abscesses and things and so forth.

I came in every day and every weekend if I there was a patient from the hospital, because I was their doctor as well. I did all the data entry, I did the analysis, I did the budgeting, I ran the money,  I ran, I mean I was the  jack of all trades, but I loved it and it was extremely important, because, and I really encourage my fellows, now my trainees to do, to do everything, not to get spoiled, because having done everything, I now can work with my administrator, I can work with my data manager, my statistician, and I understand the challenges, I understand what we are looking at. I think it’s really actually helped the research that our group has been doing, significantly, because I’ve had that hands-on experience.

And so I moved here for fifteen months after and I started…I should also say that it was three weeks after the residency. In residency, in my programme, we were working 80 to 110 hours a week. When I was in Kenya, I also thoroughly enjoyed my time living here.  I lived here from 1994 to 2002, pretty much consecutively, although I spent summers back in Seattle during that time. But thoroughly enjoyed and made lots and lots of friends. The country is spectacular, the people. I would get out for the weekends. So I actually was able to kind of live here more broadly than I did as resident. So after about three months I called up my mentor, Joan Kreiss, and I said, “You know, I think I want to stay for a full two years.” She said, “No problem.”

So, and then about that time… a little bit later, then I had to leave to, umm, my brother was getting married and so I had to leave for the US but I had this ongoing study so I needed some help. So, there’s a professor from the University of Manitoba who started the collaboration with the the STD research programme that started here between the University of Nairobi and Manitoba. I said, “You know, I need to find a good Ob/Gyn who’s interested in research, do you know anyone?” So he said, “Well, I met this, I met this doctor who’s just finished residency. Her name’s Elizabeth Bukusi and she’s at KEMRI and I think she’s looking for something to do right now.” So, somehow I found out where she was. So I walked over there,  I am shy, but not in that sort of sense. So, I walked over there, knocked on her door and she opened up the door. And of course she opened up the door to what most likely will end up being a lifelong friendship and partnership in our work.

She ended up working those three weeks while I was away, for which I was very grateful, and then getting incorporated into the research. The study was among women hospitalized with Pelvic Inflammatory Disease. We soon started an outpatient, a similar study, a parallel study looking at outpatients, or patients going to the health facility who didn’t require hospitalization, with PID, that Elizabeth ran.

And then we started a third study, the, the Principal of the College of Health Sciences, Professor Sinei, had written a project proposal and had gotten some money, but didn’t have the time to implement it, which was looking at the causes or the etiology of women who had tubal factor infertility, which is very common in many parts of southern Africa, including Kenya.

So, one study mushroomed to three studies. My life blossomed as well. Just friendships and relationships. And, then after two years, I also got very interested … at that time, this is 1995… early 96, or so. I came… something that just started to really grab me is that in my, in both PID studies, about 40 per cent of the women were living with HIV. I could cure them of PID. We had strong antibiotics, everybody got well. But I couldn’t do anything about their HIV infection. And this is the pre-HAART era, pre-HAART, way pre-PEPFAR [President’s Emergency Plan for AIDS Relief]. This is pre-HAART.

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Q: What was HAART?

A: Highly Active Anti-Retroviral Therapy

 

Q: Oh, so the medicine wasn’t even there?

A: That didn’t happen till 1996. Vancouver the AIDS meeting was like, hey, triple drug therapy works and there was a scale-up in the wealthy countries and of course….

it took longer to get into developing countries. So this is pre-HAART in the world. So I started thinking about this. What could we do to improve these people’s lives? There were certain things we knew we could do. We could give prophylaxis with bactrim, antibiotic prophylaxis. Potentially give prophylaxis against TB and so offset second opportunistic infections,we could help to look at that.

So, my first grant actually got funded, with a really good colleague, Christina Mwachari, who is also at KEMRI. She had done research on the interface of tuberculosis and HIV at KEMRI. Anyway, so we wrote this grant and submitted it to the Rockefeller Foundation and I gained the ear of the head of what was that other foundation… I think he was….what was his name?

He is now head of IAVI…….Seth Berkley, yes. So I met him at a meeting and of course I had made a budget of 200,000. Then he says, “Well, you cut it down”. Then he gives us a two-year grant for 110,000 dollars and we started doing this study looking at use…WHO had published algorithms to treat adults with opportunistic infections but had never tested them. So, we had this study. We created this cohort of HIV positive women and men in Nairobi at KEMRI.   We started to evaluate these algorithms.  And there were several publications that came out from it. I think that there was some really good work that came out of that project.

That kind of was the first project…I had this interest now in caring not just for the other infections like Pelvic Inflammatory Disease but actually trying to improve the lives of people living with HIV. This is the pre-HAART era.

 

Q: You could only improve their lives but you couldn’t cure them or treat them.

A: We could not treat, we could not treat the HIV, but we could improve, decrease the amount of disease that they had and maybe cause them, well, hopefully cause them, help them to live longer. Not like the current day that we have the triple dose.

So, that was really my start in HIV care and treatment combined with the Sexually Transmitted Disease research. I then left Kenya for a year to do my course work for my Masters in Public Health at the University of Washington but during that year I did everything I could to come back home, which home was Nairobi.

So I wrote grants and grants. I wrote that one grant for the Rockefeller Foundation but that wasn’t enough to sustain me so I wrote other grants with other investigators and we got funded and I came back… then this would be, so a year later essentially I came back. Then for the next five years, essentially what I did is I would spend about 9 months of the year living in Nairobi, working here and then I’d go back to Seattle, to the University of Washington where I transitioned from being a fellow to faculty to do my clinical work. And also just re-connect with my mentors on that side.

And the programme in the meantime was growing here. Elizabeth was taking more and more of a leadership role. During that time, of course, part of that time she was back in Seattle doing her own course work and then there were other people that got involved, interested. Nelly Mugo, who now works at the University, and also at the University of Washington, Videlis Nduba,   Christina Mwachari, so a group of trainees, if you will, but Elizabeth really stands out because obviously we’ve grown together and we support each other in many ways.

So, anyway I did everything…we got the grants and I moved back home. And then I, for the next five years, the programme really branched, had two branches and still kind of those branches continue to this day as far as the research agenda.  One of them is the prevention of HIV and sexually transmitted infections. So we started a study like looking at a contraceptive diaphragm, for example, back in those days.

And then the other element was looking at improving the lives of people living with HIV and that was work that was initially funded by Rockefeller. We then got  a grant from the World Health Organization to continue that and so forth.

And really, if you take a look at the programme today, you will see that the roots, the trunk, or the two branches of the majority of the research.

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